Women's Preventive Health Services Survey

Documents and Forms

Document Name Document Type
Women's Preventive Health Services Survey Form
WPHSS questionnaire Attachment 3. WPHSS_Survey with consent_English.docx Form
Survey screenshots - English Attachment 6. WPHSS_Survey Screenshots_English.pdf Form
Survey screenshots - Spanish Attachment 7. WPHSS_ Survey Screenshots_Spanish.pdf Form
Attachment 5. WPHSS_Web Instructions Bilingual.docx Web instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Women's Preventive Health Services Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	WPHSS questionnaire	Attachment 3. WPHSS_Survey with consent_English.docx	Yes	Yes	Fillable Fileable
Form	none	Survey screenshots - English	Attachment 6. WPHSS_Survey Screenshots_English.pdf	Yes	Yes	Fillable Fileable
Form	none	Survey screenshots - Spanish	Attachment 7. WPHSS_ Survey Screenshots_Spanish.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,338	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,338	2,338
Annual IC Time Burden (Hours)	974	974
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Web instructions	Attachment 5. WPHSS_Web Instructions Bilingual.docx	02/08/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.